Retail and Urgent Care Articles
Diagnostic accuracy of the digitally interpreted rapid influenza A and B antigen tests (DIA) was better than the traditional rapid flu tests, 77-80% sensitive vs. 53-54% sensitive. In children compared to adults, the sensitivity was 18.5 points higher for flu A and 32 points higher for flu B with the traditional rapid test; 12 and 25 points higher for the DIA respectively; 2.7% points higher for nucleic acid amplification tests (NAATs). NAATs were about 95% sensitive overall. All tests had specificity of about 98%.
There was no difference in cosmetic outcome with use of absorbable vs. nonabsorbable suture for pediatric lacerations, though there was a nonsignificant trend to absorbable being superior. There was also no difference in dehiscence or infection rate between the two.
Why do people seek emergency or urgent care? This quick systematic review of the literature identified 5 reasons.
The diagnostic accuracy of rapid streptococcal antigen testing is such that a negative test rules out disease and should not be treated; a positive test rules it in and should be treated.
Medication overuse headache (MOH), also known as rebound headache or drug-induced headache, may be the stuff of legend. The evidence for it is sketchy. The authors say, "Until the evidence is better, we should avoid dogmatism about the use of symptomatic medication."
Fluoroquinolone antibiotics were associated with idiopathic intracranial hypertension.
Patients in an ED setting with a low pretest probability based on the Wells score, and a negative D-dimer were safely ruled out for pulmonary embolism without further diagnostic imaging.
No clinical criteria were powerful diagnostic discriminators of the presence or absence of pneumonia in children, though some were fair. When in doubt, a CXR is probably warranted, with the exceptions of obvious bronchiolitis or asthma. Low SpO2 (</= 95 to 96%) or increased work of breathing were the best predictors of radiographic pneumonia in children; auscultatory findings and tachypnea were poor. You don't need a CXR if no cough, no fever, no tachypnea, and normal SpO2.
Oral steroids were of no benefit for non-asthmatic patients with bronchitis.
I couldn't state it better than the author's conclusion: "In adult patients, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children, posttussive vomiting is much less helpful as a clinical diagnostic test."
Implicit racial bias is likely influencing us in the ED, but whether that translates into impacting clinical decision making remains to be seen.
All children in the PED who were low risk for penicillin allergy on this questionnaire were confirmed to have no true penicillin allergy with skin testing.
Even small abscesses, <5cm, benefitted from antibiotics. This is contrary to some prior studies' findings that I&D alone was adequate for small abscesses.
If clinical gestalt for PE is low, use PERC to rule out PE. If not ruled out, use a validated tool to determine pretest probability of PE: Wells, Revised Geneva, or simplified versions of either score. If non-high or "unlikely" pretest probability, order D-dimer, adjusting for age (<500 or <age x 10). If D-dimer is negative, PE is ruled out. If positive, order CT pulmonary angiogram.
This was a fun article that searched the literature and dispensed with 10 myths about cellulitis.
More patients are having operative repair for displaced midshaft clavicle fractures. This meta-analysis of 6 RCTs found that the rate of nonunion was markedly reduced and final functional outcome was also improved (though not as strikingly) with operative management.
Noninvasive measurement of ejection fraction with an iPhone app is possible and very accurate. When this becomes publicly available, it will be a game changer.
In a largely adult population, those presenting to the ED with diarrhea only and no vomiting had C. difficile colitis as the cause in 10%, and almost 40% lacked risk factors.
Not only is coffee not bad for you, it could save your life! This study of over half a million people in 10 European countries found coffee consumption was associated with decreased overall mortality in men and women.
Allowing parents the option to wait and see if their child did not improve or worsened in 48 hours after the diagnosis of acute otitis media in the ED vs. filling the prescription right away resulted in a dramatic reduction in antibiotic use with little downside in this RCT.
Learn the ECG patterns for posterior MI, left main disease, the ominous isolated T-wave inversion in aVL, large upright T-wave in V1, and Wellen's warning. This full text article is mandatory reading.
History and exam features are not useless in the evaluation of patients with chest pain, but they must be used as part of a risk stratification strategy that includes ECG and troponin.
The PERC rule is a powerful diagnostic tool. If you determine a patient has low clinical gestalt for PE and all 8 PERC criteria are negative, then PE has been ruled out without checking a D-dimer or CT.
A 5 sentence letter to the NEJM editor in 1980 has been cited over 600 times to support opiate prescribing, which was not even the point of the original letter. We bought the line that opiates for legitimate pain were not addictive and didn't consider the source.
Adverse effects from antibiotics are very common, up to 20% of the time in hospitalized patients. Only use them when needed.
Use a score like CURB-65 (or CRB-65 if you don't have labs) when making clinical decisions about the disposition of patients with community acquired pneumonia.
Managing interruptions by delaying or rejecting the interruption may improve safety when they occur during critical tasks.
You need to know this decision rule cold. Before doing a head CT on any child, think through this decision aid first
It makes sense to treat an allergic reaction with an antihistamine. This study suggests that treating patients with an allergic reaction with a H1-antagonist may decrease the chance of disease progression to anaphylaxis, though the level of evidence is weak.
This simplified protocol worked well, was safe, and provided a one-size-fits-all approach to the workup of VTE. It also reduced CT use by 14%.